Current through Register 1531, September 27, 2024
(1) 211 CMR 71.21
shall apply to Medicare Select Policies, as defined in 211 CMR 71.21.
(2) No policy may be advertised as a Medicare
Select Policy, unless it meets the requirements of 211 CMR 71.21.
(3) No Issuer may offer a Medicare Select
Policy, unless that Issuer also offers a Medicare Supplement Core plan that is
not a network plan.
(4) For the
purposes of 211 CMR 71.21:
(a)
Complaint means any dissatisfaction expressed by an
Individual concerning a Medicare Select Issuer or its Network
Providers.
(b)
Grievance means dissatisfaction expressed in writing
by an Individual Insured under a Medicare Select Policy with the
administration, claims practices, or provision of services concerning a
Medicare Select Issuer or its Network Providers.
(c)
Medicare Select
Issuer means an Issuer offering, or seeking to offer, a Medicare
Select Policy.
(d)
Medicare Select Policy means a Medicare Supplement
Insurance Policy that contains Restricted Network Provisions.
(e)
Network Provider
means a provider of health care or a group of providers of health care, which
has entered into a written agreement with the Issuer to provide benefits
insured under a Medicare Select Policy.
(f)
Restricted Network
Provision means any provision which conditions the payment or
benefits, in whole or in part, on the use of Network Providers.
(g)
Service Area
means the geographic area approved by the Commissioner within which an Issuer
is authorized to offer a Medicare Select Policy.
(5) The Commissioner may authorize an Issuer
to offer a Medicare Select Policy, pursuant to 211 CMR 71.21 and Section 4358
of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the Commissioner
finds that the Issuer has satisfied all of the requirements of
211 CMR 71.00.
(6) A Medicare Select Issuer shall not issue
a Medicare Select Policy in Massachusetts until its plan of operation has been
approved by the Commissioner.
(7) A
Medicare Select Issuer shall be accredited according to the provisions of
M.G.L. c. 176O, and
211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
Carriers and such Medicare Select Issuer shall file a proposed plan of
operation and copies of all standard provider contracts according to the
provisions of
211 CMR 52.12:
Standards for Provider Contracts. The plan of operation shall
contain at least information that follows, and the carrier may satisfy any or
all of the following requirements by documenting that the information was filed
previously as part of the accreditation process under
211 CMR
52.06: Application for
Accreditation and by providing the location of the information within
that accreditation application:
(a) Evidence,
according to the provisions of
211 CMR
52.13:
Evidences of
Coverage, that all covered services that are subject to Restricted
Network Provisions are available and accessible through Network Providers,
including a demonstration that:
1. The number
of Network Providers in the Service Area is sufficient, with respect to current
and expected Policyholders, either:
a. To
deliver adequately all services that are subject to Restricted Network
Provisions; or
b. To make
appropriate referrals.
2. The Issuer has written agreements with
Network Providers describing specific responsibilities.
3. Emergency care is available 24 hours per
day and seven days per week.
4. In
the case of covered services that are subject to a Restricted Network Provision
and are provided on a prepaid basis, the Issuer has written agreements with
Network Providers prohibiting the providers from billing or otherwise seeking
reimbursement from or recourse against any Individual Insured under a Medicare
Select Policy. 211 CMR 71.21(7)(a)4. shall not apply to supplemental charges or
coinsurance amounts as stated in the Medicare Select Policy.
(b) A statement or map providing a
clear description of the Service Area.
(c) A description of the grievance procedure
to be utilized.
(d) A description
of the quality assurance program, including:
1. The formal organizational
structure;
2. The written criteria
for selection, retention and removal of Network Providers; and
3. The procedures for evaluating quality of
care provided by Network Providers, and the process to initiate corrective
action when warranted.
(e) A list and description, by specialty, of
the Network Providers.
(f) Copies
of written information proposed to be used by the Issuer to comply with 211 CMR
71.21(10).
(g) Any other
information requested by the Commissioner.
(8) A Medicare Select Issuer shall file any
proposed changes to the plan of operation according to the process for filing
material changes to the accreditation application under
211 CMR
52.06: Application for
Accreditation.
(9) A
Medicare Select Policy shall have a network, and the in network benefits
provided under such Medicare Select Policy shall be identical to either the
Medicare Supplement Core benefits, or the Medicare Supplement 1 benefits, or
the Medicare Supplement 1A benefits. A Medicare Select Policy may offer a
tiered network, but the benefits offered in each in network tier shall be
identical to either the Medicare Supplement Core benefits, the Medicare
Supplement 1 benefits, or the Medicare Supplement 1A benefits.
(10) A Medicare Select Policy shall not
restrict payment for covered services provided by non-network providers if:
(a) The services are for symptoms requiring
emergency care or are immediately required for an unforeseen illness, injury or
a condition; and
(b) It is not
reasonable to obtain services through a Network Provider.
(11) A Medicare Select Policy shall provide
payment for full coverage under the Policy for covered services that are not
available through Network Providers.
(12) A Medicare Select Issuer shall make full
and fair disclosure in writing of the provisions, restrictions and limitations
of the Medicare Select Policy to each applicant. This disclosure shall include
at least the following:
(a) An outline of
coverage sufficient to permit the applicant to compare the coverage and
premiums of the Medicare Select policy with:
1. Other Medicare Supplement Insurance
Policies offered by the Issuer; and
2. Other Medicare Select Policies or
Certificates.
(b) A
description (including address, phone number and hours of operation) of the
Network Providers, including primary care providers, specialty providers,
hospitals and other providers.
(c)
A description of the Restricted Network Provisions, including payments for
coinsurance and deductibles when providers other than Network Providers are
utilized.
(d) A description of
coverage for emergency and urgently needed care and other out-of-service area
coverage.
(e) A description of
limitations on referrals to Restricted Network Providers and to other
providers.
(f) A description of the
Policyholder's rights to purchase any other Medicare Supplement Insurance
Policy otherwise offered by the Issuer.
(g) A description of the Medicare Select
Issuer's quality assurance program and grievance procedure.
(13) Prior to the sale of a
Medicare Select Policy, A Medicare Select Issuer shall obtain from the
applicant a signed and dated form stating that the applicant has received the
information provided pursuant to 211 CMR 71.21(10) and that the applicant
understands the restrictions of the Medicare Select Policy.
(a) A Medicare Select Issuer shall have and
use procedures for hearing complaints and resolving written grievances from the
Insureds, and such procedures shall be in accordance with M.G.L. c. 176O,
M.G.L. c. 6D, and any other applicable provision of law.
(b) The grievance procedure shall be
described in the Policy and in the outline of coverage.
(c) At the time the Policy is issued, the
Issuer shall provide detailed information to the Insured describing the way
that a grievance may be registered with the Issuer.
(d) Grievances shall be handled in accordance
with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of
law.
(e) If a grievance is found to
be valid, corrective action will be taken in accordance with M.G.L. c. 176O,
M.G.L. c. 6D, and any other applicable provision of law.
(f) All concerned parties shall be notified
about the results of a grievance in accordance with M.G.L. c. 176O, M.G.L. c.
6D, and any other applicable provision of law.
(g) The Issuer shall report no later than
each March 31st to the Commissioner regarding its
grievance procedure. The report shall be in accordance with M.G.L. c. 176O,
M.G.L. c. 6D, and any other applicable provision of law in a format as
prescribed at the discretion of the Commissioner.
(14) At the time of the initial purchase, a
Medicare Select Issuer shall make available to each applicant for a Medicare
Select Policy the opportunity to purchase any Medicare Supplement Policy
offered by the Issuer.
(15) At the
request of an individual Insured under a Medicare Select Policy, a Medicare
Select Issuer shall make available to the individual Insured the opportunity to
purchase a Medicare Supplement Policy offered by the Issuer which has
comparable or lesser benefits and which does not contain a Restricted Network
Provision.
For the purposes of 211 CMR 71.21(16), a Medicare Supplement
Policy will be considered to have comparable or lesser benefits, unless it
contains one or more significant benefits not included in the Medicare Select
Policy being replaced. For the purposes of 211 CMR 71.21(16), a significant
benefit means coverage for the Medicare Part A deductible, coverage for at-home
recovery services or coverage for Part B excess charges,
(16) Medicare Select policies shall provide
for continuation of coverage in the event the Secretary of Health and Human
Services determines that Medicare Select Policies issued pursuant to 211 CMR
71.21(16) should be discontinued due to either the failure of the Medicare
Select Program to be reauthorized under law or its substantial amendment.
(a) Each Medicare Select Issuer shall make
available to each individual Insured under a Medicare Select Policy the
opportunity to purchase any Medicare Select Policy offered by the Issuer for
which the individual Insured is eligible which has comparable or lesser
benefits and which does not contain a restricted Network Provision. The Issuer
shall make the policies and available without evidence of
insurability.
(b) For the purposes
of 211 CMR 71.21(17), a Medicare Select Policy will be considered to have
comparable or lesser benefits, unless it contains one or more significant
benefits not included in the Medicare Select Policy being replaced. For the
purposes of 211 CMR 71.21(17)(b), a significant benefit means coverage for the
Medicare Part A deductible, coverage for at-home recovery services or coverage
for Part B excess charges.
(17) A Medicare Select Issuer shall comply
with reasonable requests for data made by state or federal agencies, including
the United States Department of Health and Human Services, for the purpose of
evaluating the Medicare Select Program.
